1336242213 NPI number — FIDELITY HEALTH CARE INC

Table of content: (NPI 1336242213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336242213 NPI number — FIDELITY HEALTH CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIDELITY HEALTH CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PREMIER HEALTH PHARMACY - AMC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336242213
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3170 KETTERING BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORAINE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45439-1924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-208-6534
Provider Business Mailing Address Fax Number:
937-641-2363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
1ST FLOOR-PROFESSIONAL BLDG
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45005-2584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-420-5045
Provider Business Practice Location Address Fax Number:
513-420-5679
Provider Enumeration Date:
09/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NAPIER
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
937-208-6534

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X , with the licence number: 022563650-03 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2120231 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0602584 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".